Glen Ellyn Bible Church exercises reasonable care to assure the safety of your student during all sponsored events and programs. Glen Ellyn Bible Church will make every possible attempt to contact the parent(s) or guardian(s) if an injury occurs during a sponsored event or program. In those cases where an injury does occur and the parent(s) or guardian(s) cannot be reached, Glen Ellyn Bible Church will be required to have this signed medical release on file for those minors requiring medical attention.

Student Last Name:
*

Student First Name:
*

Birthdate mm/dd/yyyy:
*

Gender
*

Male Female

Year in School:
*

Name of School
*

Student's Email:

Student's Cell:

Student's Street Address
*

Favorite pizza topping
*

Parent Names:
*

Primary Parent Email:
*

Primary Parent Cell:
*

If your student plans to go on the Senior High Winter Retreat January 13-15, 2017, please answer the following three questions:

1. Which does your Senior Higher prefer?

Hoodie Sweatshirt Noodie Sweatshirt (non-hooded)

2. Sweatshirt size
*

3. Which Saturday activity does your Senior Higher plan to participate in on the Winter Retreat:

Skiing/Snowboarding Waterpark Hangout Time at Expeditions Unlimited

Junior and Senior Highers, please continue to complete the following:

I give consent for my student (named above) to attend any Student Ministry event or program being sponsored by Glen Ellyn Bible Church between September 1, 2016 and August 31, 2017 including but not limited to the following:
* Winter Retreat
* Six Flags Great America
* Raging Waves
* Michigan Dunes
* Kane County Cougars Game
* Chicago Day
* Paint Ball
* Small Group Meetings/Outings
* Youth Conferences
* Summer Camp
* Mission Trips
* Small Group Activities
* Feed My Starving Children
In the event that he/she is injured while under the care of Glen Ellyn Bible Church and its representatives, and requires medical attention, I hereby consent to and will assume responsibility for any reasonable medical treatment as deemed necessary by the attending, licensed physician.
I further agree to hold the attending licensed physician, medical facility, Glen Ellyn Bible Church and its volunteers free and harmless from any claims, demands, and/or suits arising from authorization and provision of such medical treatment.
I understand the nature of the events/programs and do hereby release Glen Ellyn Bible Church and its representatives from any liability due to accident or injury by my child.